Hemophilic Arthritis: Bleeder's Joints

Advances and challenges in hemophilic arthropathy

Hemophilic arthropathy is a form of joint disease that develops secondary to joint bleeding and presents with synovial hypertrophy, cartilage and bony destruction. The arthropathy can develop despite clotting factor replacement and is especially disabling in the aging population. Pathobiological tissue changes are triggered by release of hemoglobin and iron deposition in the joint, but the sequence of events and the molecular mechanisms resulting in joint deterioration are incompletely understood. Treatment options other than clotting factor replacement are limited. Improvements in the treatment of hemophilia necessitate a better understanding of the processes that lead to this disabling condition and better diagnostic tools. Towards that end, studies of the molecular mechanisms leading to the arthropathy, as well as the development of sensitive imaging techniques and biomarkers are needed. These will pave the way to identify the cause of acute pain such as joint bleeding or synovitis, detect early, potentially reversible structural changes, and predict progression of disease. This review describes current imaging techniques and the development of high resolution musculoskeletal ultrasound with power Doppler to afford point-of-care diagnosis and management, the potential utility of diagnostic biomarkers, and summarizes our current knowledge of the pathobiology of hemophilic arthropathy.

Synovitis in a murine model of human factor VIII deficiency

Recurrent joint bleeding is the most common musculoskeletal manifestation of haemophilia and leads to a target joint and synovitis. The pathobiology of haemophilic synovitis (HS) is not well understood. Here the histopathological changes that occur following haemarthrosis were examined in an animal model for human HS. After two haemarthrosis, there was soft tissue and joint swelling and histological changes of acute synovitis included infiltration of the sub-synovial layer by mononuclear cells and neutrophils, thickening of the synovial membrane with villus formation, and hyperplasia of blood vessels. Subacute changes were evident after three haemarthrosis; muscle atrophy was present and an intense mononuclear cell infiltrate filled the sub-synovial space. There was destruction of articular surfaces and loss of cartilage. Seventeen months after three haemarthrosis, chronic joint changes included gross deformity and loss of congruence due to dense fibrotic tissue filling the joint space. The mononuclear inflammatory cell infiltrate and thickened synovial membrane persisted. Pits and erosions of articular surfaces and sub-chondral cysts were present. There was fibro-cartilage and new bone formation. This model of human HS should be useful to fully evaluate the biochemical and molecular changes that occur following joint bleeding and to test novel therapeutics to prevent HS.

Functional kinesiology in haemophilia, an area yet to be explored

In haemophilic arthropathy there is a progressive limitation of the range of motion (ROM) which may lead to disabilities in the activities of daily living (ADL). In the literature the pathology of haemophilic arthropathy is described extensively, but only one paper describing functional limitations caused by limited range of motion (LOM) in haemophilia was found. The aim of the pilot study was to estimate on theoretical grounds, how many patients with haemophilia might suffer from functional disabilities.

MATERIAL

ROM of elbows, knees and ankles of 155 Haemophilia A and B patients.

METHODS

Flexion and extension were measured with an ordinary goniometer. The ROM of joints of patients with haemophilia was compared with normal values.

RESULTS

39 of 155 patients had a normal ROM in both elbows; 22 in one elbow; 34 patients had disabilities in ADL with both arms; 14 with one arm; 18 were able to compensate; 89 had no problems; 79 of 155 patients had a near normal ROM of both knees; 38 patients could not ride an ordinary bicycle.

CONCLUSION

Only limited data are available concerning the normal ROM needed for individual ADL. Until additional data are available, it is not possible to predict which patients will be disabled in their activities of daily living and individual counselling should be done during the yearly outpatient comprehensive care clinics. Conservative and surgical measures should be taken to ensure elbow flexion of at least 120 degrees and knee flexion of 100 degrees for Western societies. In Asian countries patients with haemophilia need maximum knee flexion and ankle dorsi flexion.

Case report: arthropathy as the presenting symptom in hereditary hemochromatosis

Hemochromatosis is characterized by excessive absorption and subsequent deposition of iron in various organs and is prevalent in 1 out of 20,000 hospitalized patients. Most patients with hereditary hemochromatosis (HHC) become symptomatic between the ages of 50 and 60 years. Distinct forms of arthritis have been associated with HHC and may be the initial clinical manifestation in some patients. This is a case of a patient who had chronic hip and back pain and painless swelling over the knuckles. Radiographs revealed classical signs of HHC. Early recognition and prompt institution of phlebotomy can improve the outcome of patients with HHC.

Loss of elbow and wrist motion in hemophilia

The longitudinal changes in elbow and wrist motion for 48 patients with hemophilia were reviewed to determine the effect of recurrent hemarthroses. The average age of the patients at the time of followup was 23 years 9 months. The average duration of followup was 10.8 years. The patients were divided into 3 age groups: younger than age 15 years (14 patients), age 15 to 25 years (11 patients), and older than age 25 years (23 patients). For patients older than age 25 years, pronation, supination, elbow flexion and extension, wrist flexion and extension, and ulnar deviation were significantly decreased relative to patients younger than age 15 years. Pronation was the first motion to show a significant change, decreasing by 19% in patients age 15 to 25 years and by 31% in patients older than age 25 years. Loss of elbow extension showed the greatest change. In cases of severe hemophilic arthropathy of the elbow, synovectomy and radial head excision decreased elbow pain and bleeding episodes and improved supination and pronation.

Rheumatic manifestations of haemochromatosis

Haemochromatosis (HC) is a group of phenotypically heterogeneous clinical syndromes, which may have a common molecular basis. Classical genetic haemochromatosis (GHC) is one of these syndromes and is a disorder of iron storage due to an increase in intestinal iron absorption, which results in progressive and massive iron deposition leading to fibrosis and organ malfunction. The liver, pancreas, heart and pituitary are commonly involved. There is a specific arthropathy and an association with osteoporosis. Clinically, the arthropathy may resemble rheumatoid arthritis, with acute attacks of inflammation associated with bilateral destruction of the metacarpophalangeal joints. However, bony joint swelling may occur, suggestive of osteoarthritis. Hip arthritis may be unduly severe and disabling. Haemochromatosis arthritis is composed of three radiographic categories: isolated chondrocalcinosis, hypertrophic osteoarthritis which is indistinguishable from pyrophosphate associated arthropathy, and disease specific changes such as subchondral radiolucency of the femoral head, hook-like osteophytes on the metacarpal heads and a degenerative predilection for the metacarpophalangeal joint rather than the scapholunate. The characteristic histological changes are: abnormal amounts of iron deposits, little or no signs of synovial inflammation and CPPD deposition. Subchondral radiolucency of the femoral head and atypical stripping of the cartilage from the subchondral bone are thought to be specific radiographic and histological changes of HC. The pathogenesis of HC arthritis has been associated with the presence of iron in joint tissue, a defect in cartilage metabolism and immunological dysfunction. Treatment has little effect on clinical, radiological or histological progression.

[Consequences of hemarthrosis for the knee joint (author's transl)]

The presence of an hemarthrosis generally is a sign of a particularly severe joint lesion. Arthrous alterations appearing post-traumatically can therefore be due to the extent of the joint lesion as well as to the accompanying hemarthrosis. A group of 24 young adult rabbits was submitted to morphologic examinations in order to find out in which way an isolated hemarthrosis can be responsible of degenerative cartilage alterations. At intervals of eight days each, 3 cm3 of their own blood were injected into both knee joints of the rabbits. One knee joint was immobilized, the other was mobile. The results prove that the hemarthrosis represents a considerable risk with regard to the trophism of the concerned joint. A direct enzymatic damage to the joint cartilage alone or in combination with trophical alterations appearing later on can lead to a formation and aggravation of arthrosis. The degenerative alterations are increased in an immobilized joint. Bearing in mind these alterations, the conclusion is drawn for clinical practice that the hemarthrosis has to be considered when establishing both diagnosis and therapy plan (punction, joint lavage, drainage, immobilization as early as possible).

Importance of platelets in increased vascular permeability evoked by experimental haemarthrosis in synovium of the rat

Increased vascular permeability of synovium induced by experimental haemarthrosis was studied in the stifle joint of the rat. Abnormal permeability was detected by injecting animals intravenously with colloidal carbon and examining the synovial vessels for intramural deposits of carbon. Both fresh and heparinized whole blood injected into the joint induced a marked permeability response of synovial venules which persisted for 18 hours. Platelets suspended in heparinized Tyrode solution induced a similar response, but one lasting only 12 hours. The permeability effects of suspensions of leucocytes and erythrocytes on the synovial vasculature were relatively mild and were maximal 5 and 12 h respectively after intra-articular injection. Heparinized platelet-free plasma had no significant permeability effects. These results indicate that platelets may play an important role in the pathogenesis of synovial inflammation in haemarthrosis.

Arthrocentesis of the knee in acute hemophilic arthropathy

In 27 children and young adults with hemophilia presenting acutely painful distended intra-articular hemorrhages of the knee, aspiration was carried out and the patients were followed for a minimum of 24 months. Seventeen patients with classical hemophilia were found to have less than 1 percent of normal plasmal level of antihemophilic factor (AHF). Of the remainder, five were Factor IX, plasma thromboplastin component (PTG), deficient, whereas two patients had Von Willebrand's disease. Aspiration was routinely done in an outpatient clinic, followed by immediate discharge with return to regular activity levels within 48 hours. There were no infections nor rehemorrhages attributable to aspiration technique.

A comparison of thermography, radioisotope scanning and clinical assessment of the knee joints in haemophilia

Thermography, radioactive scanning and clinical assessment of the knee joints of a series of patients with haemophilia or Christmas disease have been performed. A positive correlation was found between the abnormalities of the thermograms, radioactive scans and the clinical signs in acute haemarthrosis, but not in chronic haemophilic joint disease nor in patients without clinical joint disease. No correlation between the thermograms, radioactive scans and the number of previous joint bleeds was shown. Thermography and radionuclide scanning provide rapid means of quantifying changes within the haemophilic joint and may be useful in assessing treatment of haemophilic haemarthrosis.

Ultrastructural characteristics of the synovial membrane in idiopathic haemochromatosis

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MUSCULOSKELETAL COMPLICATIONS OF HEMOPHILIA

Persons with hemophilia may be crippled by hemorrhages into soft tissue, the pressure destroying nerve and muscle. Recurrent bleeding into joints produces severe arthritis with synovitis and damage to cartilage and bone. The resulting deformities, even of long standing, may be greatly lessened, so far as impairment of function is concerned, by conservative orthopedic treatment. Treatment also may slow the progress of crippling deformities.

Experimental production of pigmented villonodular synovitis in dogs

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